Health workers’ views on factors affecting caregiver engagement with bubble CPAP

BMC Pediatrics, Volume 20, No. 1, Year 2020

Interpretation

Background: Severe respiratory distress is a leading cause of mortality among neonates in Malawi. Despite evidence on the safety, cost effectiveness and efficacy of bubble continuous positive airway pressure (CPAP) in managing the condition, its use in Malawian health facilities is limited and little is known about caregivers’ engagement with perspectives of bubble CPAP. The purpose of this study was to explore caregiver perspectives for bubble CPAP at both central and district hospitals and key factors that enable effective caregiver engagement in Malawi. Methods: This was a descriptive qualitative study employing secondary analysis of 46 health care worker in-depth interviews. We interviewed the health workers about their thoughts on caregiver perspectives regarding use of bubble CPAP. We implemented the study at a tertiary facility and three district hospitals in southern Malawi. This was a part of a larger study to understand barriers and facilitators to implementing neonatal innovations in resource-constrained hospitals. Interviews were thematically analysed in NVivo 12 software (QSR International, Melbourne, Australia). Health workers were purposively selected to include nurses, clinicians and district health management involved in the use of bubble CPAP. Results: Emerging issues included caregiver fears around bubble CPAP equipment as potentially harmful to their new-borns and how inadequate information provided to caregivers exacerbated knowledge gaps and was associated with refusal of care. However, good communication between health care providers and caregivers was associated with acceptance of care. Caregivers’ decision-making was influenced by relatives and peer advocates were helpful in supporting caregivers and alleviating fears or misconceptions about bubble CPAP. Conclusions: Since caregivers turn to relatives and peers for support, there is need to ensure that both relatives and peers are counselled on bubble CPAP for improved understanding and uptake. Health workers need to provide simplified, accurate, up-to-date information on the intervention as per caregivers’ level of understanding. Notably, contextualised comprehensible information will help alleviate caregivers’ fear and anxieties about bubble CPAP. This is a secondary analysis of 46 semi-structured, in-depth interviews with health workers in southern Malawi on their experiences of using bubble CPAP as part of a larger project, “Integrating a neonatal healthcare package for Malawi” which seeks to inform the scale-up of low-cost and locally appropriate innovations to improve newborn care at low-resource health facilities. The project is a part of the Innovating for Maternal and Child Health in Africa (IMCHA) initiative funded by the Canadian International Development Research Centre (IDRC), Global Affairs Canada (GAC) and the Canadian Institutes for Health Research (CIHR). Through health worker interviews, we sought to understand caregivers’ perspectives on their experiences on using bubble CPAP. The study was conducted at a tertiary hospital and three secondary level hospitals (hereafter referred to as district 1, district 2 and district 3) in the southern region of Malawi. The tertiary and districts 1 and 3 are public government facilities and provide services for free while district 2 is a private mission hospital. While the mission hospital charges a fee for its services, it serves as a referral centre for the district and clients referred from public facilities access care for free. The tertiary facility administers bubble CPAP in the nursery unit and paediatric nursery ward. The district facilities all provide bubble CPAP in smaller rooms within the nursery units. In total, there are two tertiary and 11 district facilities in southern Malawi. The facilities were chosen in consultation with Ministry of Health. More information is provided a facility assessment paper (see Kawaza et al., 2020 [14] and a primary paper on bubble CPAP (see Nyondo- Mipando et al., 2020 [15]. The sample was purposively drawn to include health workers involved in delivery and/or decision-making for newborn care at the four health facilities. At the tertiary facility, we recruited nurses and clinicians working in neonatal units, nurses in charge of the ward, registrars and pediatric consultants while at district facility, we recruited nurses and clinicians engaged in neonatal units plus district health officers (DHOs), district medical officers (DMOs), district nursing officers (DNOs), nurses in charge of the pediatric ward. We approached health workers in person and or by phone and asked for an interview after briefing them on the study. Based on the number of health workers that interfaced with bubble CPAP and the limited number of staff available for neonatal care especially at district hospitals, a sample size of 10–15 participants was estimated at each site as being needed to achieve data saturation with a variety of perspectives. We used in semi-structured interview guide for its ability to allow participants to detail their personal experiences. A team of five trained data collectors conducted 46 interviews with health care workers on perspectives of caregivers towards bubble CPAP. Data collection took place between June and August 2018 (for more information, see Nyondo- Mipando et al., 2020 [15]). We piloted the interview guide and made corrections to the tools before data collection commenced. Data from the pilot phase was not included in the final analysis. Face-to-face interviews were conducted in a secluded place within the facilities and lasted 30–60 min each. Participants provided written informed consent and filled out a demographics form. Interview questions focussed on training, initiation, monitoring, differences in opinions, perception and personal experiences and perception on caregiver understanding of bubble CPAP. Data was analyzed using an iterative thematic approach where the research team first familiarized themselves with the interviews to develop a coding framework to be analyzed using NVivo 12 software (QSR International, Melbourne, Australia). The iteration process was applied as developed by Srivastava, 2009 [16] while the thematic analysis was applied as developed by Braun and Clark, 2006 [17]. Analysis commenced during data collection period and involved a constant loop process with researchers reflectively referring back to raw data. SS and ALNM listened to the audios in both languages (Chichewa and English) while MLWK reviewed the transcripts after translation to English. All three read the transcripts several times to familiarize with the data and then generated initial codes together. Where differences arose, all three researchers discussed the suggested codes, constantly referring bact to the raw data until a consensus was reached. The initial transcript was coded by SS and MLWK and codes were compared and areas that differed were discussed between the two researchers until a consensus was reached regarding the most plausible code for that aspect. Thereafter, ALNM checked the transcipt and if any differences arose, all three researchers constantly referred back to the raw data. After completion of each transcript coding, all three researchers referred the coded transcript back to the raw data, objectively reflecting if the codes sppoke to the data. We searched for themes from the codes by organising all similar and recurrent. We examined each code for further subcategories [17]. We reviewed the themes and this resulted in maintaining, combining, separating or discarding themes as necessary [17] and the decision to change was dependent on the richness and breadth of the proposed theme to accommodate other sub themes. For instance, we combined findings on support received from significant others into one theme. We did this to ensure that all themes presented had rich data that substantiated the theme, which resulted into discarding of themes without supporting data. Before discarding, SS and MWLK also reflectively referred back to the raw data to verify if we were making the right decision. We refined the themes and verified our results against the digital recordings. The refined themes were checked for quality by ALNM.

AI Digest

Study Justification:

– Severe respiratory distress is a leading cause of mortality among neonates in Malawi.
– Limited use of bubble continuous positive airway pressure (CPAP) in Malawian health facilities.
– Little is known about caregivers’ engagement with bubble CPAP.
– Need to explore caregiver perspectives and factors that enable effective caregiver engagement.

Study Highlights:

– Descriptive qualitative study using secondary analysis of 46 health care worker interviews.
– Explored caregiver perspectives for bubble CPAP at central and district hospitals in Malawi.
– Identified caregiver fears, inadequate information, and good communication as key factors.
– Relatives and peer advocates played a role in supporting caregivers.
– Recommendations include counseling relatives and peers, providing simplified and accurate information, and contextualized communication.

Study Recommendations for Lay Reader:

– Ensure that relatives and peers are counseled on bubble CPAP for improved understanding and uptake.
– Health workers should provide simplified, accurate, up-to-date information on the intervention.
– Contextualized comprehensible information will help alleviate caregivers’ fear and anxieties about bubble CPAP.

Study Recommendations for Policy Maker:

– Support training and counseling programs for relatives and peers on bubble CPAP.
– Provide resources for health workers to effectively communicate with caregivers.
– Allocate funding for the development and dissemination of simplified and accurate information materials.

Key Role Players:

– Ministry of Health
– Health care providers (nurses, clinicians, district health management)
– Relatives and peers of caregivers
– Training and counseling programs

Cost Items for Planning Recommendations:

– Training and counseling programs
– Development and dissemination of information materials
– Resources for effective communication (e.g., training, equipment)
– Staffing and personnel for implementation

Strength of Evidence

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is based on a descriptive qualitative study employing secondary analysis of 46 health care worker in-depth interviews. The study was conducted at a tertiary facility and three district hospitals in southern Malawi. The interviews were thematically analyzed using NVivo 12 software. The study provides insights into caregiver perspectives and factors affecting engagement with bubble CPAP. However, the abstract does not mention the specific findings or conclusions of the study. To improve the evidence, the abstract could include a summary of the key findings and their implications for improving caregiver engagement with bubble CPAP.

Abstract

This is a secondary analysis of 46 semi-structured, in-depth interviews with health workers in southern Malawi on their experiences of using bubble CPAP as part of a larger project, “Integrating a neonatal healthcare package for Malawi” which seeks to inform the scale-up of low-cost and locally appropriate innovations to improve newborn care at low-resource health facilities. The project is a part of the Innovating for Maternal and Child Health in Africa (IMCHA) initiative funded by the Canadian International Development Research Centre (IDRC), Global Affairs Canada (GAC) and the Canadian Institutes for Health Research (CIHR). Through health worker interviews, we sought to understand caregivers’ perspectives on their experiences on using bubble CPAP. The study was conducted at a tertiary hospital and three secondary level hospitals (hereafter referred to as district 1, district 2 and district 3) in the southern region of Malawi. The tertiary and districts 1 and 3 are public government facilities and provide services for free while district 2 is a private mission hospital. While the mission hospital charges a fee for its services, it serves as a referral centre for the district and clients referred from public facilities access care for free. The tertiary facility administers bubble CPAP in the nursery unit and paediatric nursery ward. The district facilities all provide bubble CPAP in smaller rooms within the nursery units. In total, there are two tertiary and 11 district facilities in southern Malawi. The facilities were chosen in consultation with Ministry of Health. More information is provided a facility assessment paper (see Kawaza et al., 2020 [14] and a primary paper on bubble CPAP (see Nyondo- Mipando et al., 2020 [15]. The sample was purposively drawn to include health workers involved in delivery and/or decision-making for newborn care at the four health facilities. At the tertiary facility, we recruited nurses and clinicians working in neonatal units, nurses in charge of the ward, registrars and pediatric consultants while at district facility, we recruited nurses and clinicians engaged in neonatal units plus district health officers (DHOs), district medical officers (DMOs), district nursing officers (DNOs), nurses in charge of the pediatric ward. We approached health workers in person and or by phone and asked for an interview after briefing them on the study. Based on the number of health workers that interfaced with bubble CPAP and the limited number of staff available for neonatal care especially at district hospitals, a sample size of 10–15 participants was estimated at each site as being needed to achieve data saturation with a variety of perspectives. We used in semi-structured interview guide for its ability to allow participants to detail their personal experiences. A team of five trained data collectors conducted 46 interviews with health care workers on perspectives of caregivers towards bubble CPAP. Data collection took place between June and August 2018 (for more information, see Nyondo- Mipando et al., 2020 [15]). We piloted the interview guide and made corrections to the tools before data collection commenced. Data from the pilot phase was not included in the final analysis. Face-to-face interviews were conducted in a secluded place within the facilities and lasted 30–60 min each. Participants provided written informed consent and filled out a demographics form. Interview questions focussed on training, initiation, monitoring, differences in opinions, perception and personal experiences and perception on caregiver understanding of bubble CPAP. Data was analyzed using an iterative thematic approach where the research team first familiarized themselves with the interviews to develop a coding framework to be analyzed using NVivo 12 software (QSR International, Melbourne, Australia). The iteration process was applied as developed by Srivastava, 2009 [16] while the thematic analysis was applied as developed by Braun and Clark, 2006 [17]. Analysis commenced during data collection period and involved a constant loop process with researchers reflectively referring back to raw data. SS and ALNM listened to the audios in both languages (Chichewa and English) while MLWK reviewed the transcripts after translation to English. All three read the transcripts several times to familiarize with the data and then generated initial codes together. Where differences arose, all three researchers discussed the suggested codes, constantly referring bact to the raw data until a consensus was reached. The initial transcript was coded by SS and MLWK and codes were compared and areas that differed were discussed between the two researchers until a consensus was reached regarding the most plausible code for that aspect. Thereafter, ALNM checked the transcipt and if any differences arose, all three researchers constantly referred back to the raw data. After completion of each transcript coding, all three researchers referred the coded transcript back to the raw data, objectively reflecting if the codes sppoke to the data. We searched for themes from the codes by organising all similar and recurrent. We examined each code for further subcategories [17]. We reviewed the themes and this resulted in maintaining, combining, separating or discarding themes as necessary [17] and the decision to change was dependent on the richness and breadth of the proposed theme to accommodate other sub themes. For instance, we combined findings on support received from significant others into one theme. We did this to ensure that all themes presented had rich data that substantiated the theme, which resulted into discarding of themes without supporting data. Before discarding, SS and MWLK also reflectively referred back to the raw data to verify if we were making the right decision. We refined the themes and verified our results against the digital recordings. The refined themes were checked for quality by ALNM.

Materials

N/A

Innovations

Based on the provided description, here are some potential innovations that could improve access to maternal health:

1. Mobile Health (mHealth) Applications: Develop mobile applications that provide simplified, accurate, and up-to-date information on maternal health interventions, including bubble CPAP. These apps can be easily accessible to caregivers, providing them with the necessary knowledge and guidance.

2. Peer Advocacy Programs: Establish peer advocacy programs where trained individuals who have successfully used bubble CPAP can support and educate other caregivers. These programs can help alleviate fears and misconceptions, as well as provide emotional support to caregivers.

3. Community Education Campaigns: Conduct community education campaigns to raise awareness about bubble CPAP and its benefits. These campaigns can involve community leaders, healthcare workers, and local organizations to disseminate information and address any concerns or misconceptions.

4. Training for Healthcare Providers: Provide comprehensive training for healthcare providers on effective communication and counseling skills. This will enable them to provide clear and contextualized information to caregivers, addressing their fears and anxieties about bubble CPAP.

5. Integration of Maternal and Neonatal Care: Promote the integration of maternal and neonatal care services to ensure that caregivers receive comprehensive care throughout the pregnancy, childbirth, and postpartum periods. This can improve access to bubble CPAP and other maternal health interventions.

6. Task Shifting: Explore the possibility of task shifting, where certain aspects of maternal health care, such as counseling and education, can be delegated to trained community health workers or midwives. This can help alleviate the workload of healthcare providers and improve access to care.

7. Telemedicine: Utilize telemedicine technologies to provide remote consultations and support for caregivers in rural or remote areas. This can enable healthcare providers to remotely assess and guide caregivers on the use of bubble CPAP, improving access to specialized care.

These innovations can help address the factors affecting caregiver engagement with bubble CPAP and improve access to maternal health services in Malawi.

AI Innovations Description

Based on the description provided, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Improve caregiver engagement and communication: It is important to address the fears and concerns of caregivers regarding the use of bubble CPAP equipment. This can be done by providing adequate information and education to caregivers about the benefits and safety of bubble CPAP. Health workers should ensure that caregivers receive simplified, accurate, and up-to-date information about the intervention, tailored to their level of understanding. This can help alleviate caregivers’ fears and anxieties, leading to increased acceptance and uptake of bubble CPAP.

2. Involve relatives and peer advocates: Caregivers often turn to their relatives and peers for support and advice. To improve understanding and uptake of bubble CPAP, it is crucial to involve and counsel both relatives and peer advocates. By providing them with comprehensive information about bubble CPAP, they can play a supportive role in addressing caregivers’ fears and misconceptions. This can help create a supportive environment for caregivers and increase their confidence in accepting and using bubble CPAP.

3. Contextualize information: It is important to provide contextualized and comprehensible information to caregivers. This means tailoring the information to their specific cultural, social, and educational backgrounds. By presenting information in a way that is easily understood and relatable to caregivers, it can help bridge knowledge gaps and improve their understanding of bubble CPAP. This can ultimately lead to increased acceptance and utilization of the intervention.

By implementing these recommendations, it is possible to develop an innovation that improves access to maternal health by addressing caregiver perspectives and enhancing their engagement with bubble CPAP.

AI Innovations Methodology

Based on the provided description, the study aims to explore caregiver perspectives on the use of bubble continuous positive airway pressure (CPAP) for managing severe respiratory distress in neonates in Malawi. The study conducted 46 in-depth interviews with health workers to gather insights on caregiver engagement with bubble CPAP and identify key factors that enable effective engagement.

To improve access to maternal health, the following innovations could be considered:

1. Mobile Health (mHealth) Solutions: Develop mobile applications or text messaging services to provide pregnant women and new mothers with information, reminders, and support regarding maternal health. These solutions can help overcome barriers such as limited access to healthcare facilities or lack of awareness about available services.

2. Telemedicine: Implement telemedicine services to enable remote consultations between healthcare providers and pregnant women or new mothers. This can improve access to specialized care, especially in rural or underserved areas where healthcare facilities are limited.

3. Community Health Workers: Train and deploy community health workers to provide maternal health education, antenatal care, and postnatal support in remote or marginalized communities. These workers can bridge the gap between healthcare facilities and communities, improving access to essential maternal health services.

4. Maternal Health Vouchers: Introduce voucher programs that provide financial assistance to pregnant women, allowing them to access quality maternal health services. These vouchers can cover costs related to antenatal care, delivery, and postnatal care, ensuring that financial constraints do not hinder access to care.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the target population: Identify the specific group of pregnant women or new mothers who would benefit from the innovations. Consider factors such as geographic location, socioeconomic status, and existing barriers to access.

2. Collect baseline data: Gather information on the current state of maternal health access in the target population. This can include data on healthcare utilization, maternal health outcomes, and barriers to access.

3. Model the impact: Use mathematical modeling techniques to simulate the potential impact of the recommended innovations on improving access to maternal health. This can involve estimating changes in healthcare utilization, reduction in barriers, and improvements in maternal health outcomes.

4. Sensitivity analysis: Conduct sensitivity analysis to assess the robustness of the model and explore the potential variations in outcomes based on different assumptions or scenarios. This can help identify key factors that influence the impact of the innovations.

5. Validate the model: Validate the model by comparing the simulated results with real-world data, if available. This can help ensure the accuracy and reliability of the model’s predictions.

6. Policy recommendations: Based on the simulated impact, provide policy recommendations on the implementation and scale-up of the recommended innovations. Consider factors such as cost-effectiveness, feasibility, and sustainability.

It is important to note that the specific methodology for simulating the impact of these recommendations may vary depending on the available data, resources, and context.

Author

Dima Health

Statistics:

Citations: 3

Identifiers:

DOI: 10.1186/s12887-020-02088-8

Research Areas:

Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants, Technology and Innovations

Study Countries:

Malawi

Study Design:

Cross Sectional Study, Grounded Theory, randomised-control-trial

Study Approach:

Qualitative